Implementation of Pediatric HIV Prevention and Care Guidelines in Routine Settings: Outcomes among HIV-Exposed Infants in DR Congo (2007-2013)

Outcomes of HIV-exposed infants remain inadequately studied, particularly in resource-deprived settings. We conducted an observational study of 1707 mother-infant pairs who received care in a comprehensive HIV program in Kinshasa, DR Congo during 2007-2013. The study resulted in two manuscripts, one which describes temporal changes in the outcomes of HIV-exposed infants and one that assesses the relationship between infant retention in care and the provision of combination antiretroviral therapy (cART) to their HIV-infected mothers. The first manuscript suggests there have been encouraging improvements over time in the outcomes of HIV-exposed infants but that continued efforts are needed. Accounting for competing risks (e.g. death), we estimated the cumulative incidences of having an initial specimen collected for HIV virologic testing, loss to follow-up (LTFU), HIV transmission, and death through age 18 months, as well as cART initiation among HIV-infected infants through age 24 months. The 18-month cumulative incidence of specimen collection increased from 73% (95% confidence limit [CL]: 68-78%) for infants enrolled in 2007-2008 to 99% (95% CL: 98-100%) for infants enrolled in 2011-2012. The 18-month cumulative incidence of HIV declined from 15% (95% CL: 11-21%) for infants enrolled in 2007-2008 to 8% (95% CL: 6-11%) for infants enrolled in 2011-2012 and death declined from 8% (95% CL: 5-11%) to 3% (95% CL: 2-5%). The 18-month cumulative incidence of LTFU did not improve, with 18-month cumulative incidences of 18% (95% CL: 14-22%) for infants enrolled in 2007-2008 and 18% (95% CL: 15-21%) for infants enrolled in 2011-2012. Among HIV-infected infants, the 24-month cumulative incidence of cART increased from 61% (95% CL: 43-75%) to 97% (95% CL: 82-100%); the median age at cART decreased from 17.9 to 9.3 months. In the second manuscript, we show that increasing access to cART for pregnant women could improve retention in care of their HIV-exposed infants. The 18-month cumulative incidence of LTFU was 9% among infants whose mothers had initiated cART by infant enrollment and 19% among infants whose mothers had not yet initiated cART (Gray's p-value